Dialectical Behavioral Therapy (DBT) can be used for therapy patients with a vast array of needs and conditions; however, it is primarily associated with borderline personality disorder (BPD). In fact, the founder of DBT herself, Dr. Marsha Linehan, struggled with BPD — though at first, she didn’t know it.1 Thus for those facing a new BPD diagnosis, DBT is a common recommendation for treatment.
But how does it work to help BPD specifically? Let’s dive into this topic.
What Is DBT?
DBT was established in the 1980s by Marsha Linehan, as a treatment for suicidal patients.2 At the time, cognitive behavioral therapy (CBT) was the primary therapy used to treat suicidal patients, but Dr. Linehan found that many patients dropped out of treatment before completing it. CBT alone was not helpful to suicidal patients, because it focused solely on change strategies, not acceptance.
DBT was built to help patients balance dialectics: two seemingly opposing things that can both be true. The main dialectic to focus on was that of both change and acceptance — accepting that certain behaviors or coping strategies may have helped you in the past, and changing them when they are no longer effective.
As Dr. Linehan continued to develop DBT, it became the first specialized treatment for BPD.
Stages of DBT
DBT has five stages that patients and therapists will move through over the course of the one-year therapy treatment. These include:
- Commitment to Treatment. The patient commits to accepting who they are and changing behaviors that might be threatening to their life worth living.
- Stabilization to Achieve Behavioral Control. In this stage, the patient and therapist will identify target behaviors that may be getting in the way of the patient’s well-being. They begin with self-destructive target behaviors, then move onto therapy-interfering behaviors, and then focus on quality of life. Patients will track when they turn to these behaviors, what triggers them, and what their emotional state is when they engage in these behaviors.
- Attend to Quiet Desperation. As the patient gets better at identifying and changing their target behaviors, they may still have a feeling of suffering in silence. During this stage, they learn how to meet their needs and get the help they need.
- Increase Self-Respect and Quality of Life. The goal of DBT is to help patients learn to live their life worth living. With the disruptive target behaviors changing and quiet desperation addressed, the patient begins to focus on boosting their self-respect and learning how to live their life worth living.
- Gaining Deeper Meaning. The patient gains an understanding of their spiritual existence and the ways that all of their forms of wellness are interconnected.
How DBT Treatment Works
DBT typically lasts one year and can be an intensive form of therapy. Patients will have one individual therapy session per week, as well as one group therapy session per week. The individual session takes about an hour, while the group therapy session typically takes 1-2 hours. There are also as-needed consultations: when a patient finds themselves in a moment of high distress, they can reach out to their therapist for “phone coaching.”
During individual sessions, patients go over their diary card: a log which tracks their target behaviors and emotions. They discuss what they felt that triggered the target behavior and how the behavior impacted their emotions. Like CBT, patients will go through the link between thoughts, emotions, and behaviors. Then the patient and therapist will figure out solutions to their target behaviors and commit to working on those solutions.
Finally, there are also weekly consultations amongst therapists. DBT can be a heavy therapy for both the patient and therapist. Weekly consultations help therapists to meet their own needs and better understand their patients’ needs.
What Is BPD?
Borderline personality disorder is a disorder impacting up to 6% of the general population.3 It is characterized by pervasive emotional dysregulation that stems from biological dysfunction. In most cases, as a child, patients with BPD tried to express their feelings and were ignored or invalidated. They learned that their needs were only attended to when they exhibited a heightened level of emotions.
Because healthy emotional regulation skills were not taught or followed, patients with BPD grow up to continue to manage emotions in a dysregulated way. That childhood vulnerability can express itself as impulsivity. Patients with BPD are also often highly critical of themselves. 8.11% of those with BPD spend time in outpatient care at some point, and 20% go into inpatient care at some point.3
There is also a high risk of suicide or self-harm amongst patients with BPD. As many as 69-80% of patients with BPD have suicidal thoughts or exhibit self-harm behaviors. 75% have had at least one suicide attempt. 10% of patients with BPD die by suicide.4 This is why there was so much overlap in Marsha Linehan’s work with suicidal patients and those with BPD.
DBT Skill Sets
So how does DBT actually treat BPD? Primarily through use of its four main skill sets: mindfulness, distress tolerance, emotional regulation, and interpersonal effectiveness. These are covered in order through group therapy, with examples given as well as weekly homework. They may also be referenced throughout individual therapy.
Mindfulness
Mindfulness is all about being in the here and now, not focusing on the past or the present. This can help patients stop emotional avoidance, as well as catastrophizing. Some exercises used in mindfulness include:
- Focusing on a single minute or moment
- Record three minutes of thought
- Thought defusions
- Describing emotions
- Mindful breathing and mindful awareness of emotions
- Mindful “I” statements
- Meditations of loving kindness towards the self
Wise Mind in DBT
“Wise mind” a concept that frequently comes up in DBT. It is posited to be a state of mind halfway between “rational mind” and “emotional mind.” In rational mind, you try to focus on only the facts and avoid your emotions completely. In emotional mind, you focus so much on emotions that you may make impulsive decisions. Wise mind involves recognizing your emotions and validating them, as well as looking at what is practical and effective in the moment. To reach wise mind, it’s important to practice mindfulness and avoid avoidance.
Distress Tolerance
Distress tolerance helps patients to deal with overwhelming emotions by distracting themselves, relaxing, or coping. The goal of distress tolerance is not to make the emotion completely disappear. Rather, it helps patients to self-soothe and lower their distress to the point that they can then problem solve.
Radical acceptance is one tricky element of distress tolerance. It is the process of accepting things even when they are unpleasant. This does not mean saying that everything is okay when it isn’t; rather it is looking at your situation honestly, accepting that it is what it is, and figuring out what to do from there. For instance, someone with a substance addiction may have to radically accept that they deeply want to use in that moment, but that it wouldn’t be helpful for them.
Distress tolerance can also help to distract patients from engaging in self-harm. Some distractions include:
- Squeezing a cube of ice
- Snapping a rubber band
- Drawing on self with a red felt tip marker
- Jaw faces on balloons and pop them
- Throw socks against the wall
- Do pleasant activities
- Do tasks and chores instead
- Engage the senses with something you enjoy
Emotion Regulation
Because emotion dysregulation is such a key element of BPD, emotion regulation is an important skill for DBT patients to learn. Part of that includes accepting that emotions are not themselves bad. In fact, they’re necessary for survival. Emotions are signals to the body that tell you what you need to know. The key is understanding the difference between primary and secondary emotions.
Primary emotions are your initial reaction to a situation. For instance, if a friend criticizes you, your initial emotion may be hurt. Secondary emotions are a reaction to the primary emotion. If you feel hurt because a friend criticized you, your reaction might be to protect yourself with anger. DBT works to regulate the secondary emotion, as the primary emotion cannot be controlled.
In DBT, patients learn to recognize emotions and how they react to them, as well as how their actions impact their emotions both in the short term and long term. Patients will log emotions in their diary card to better identify them. They may notice the time between emotions. They will also work to understand their vulnerabilities — both physical and cognitive. By understanding these vulnerabilities they can remove barriers to experiencing healthy emotions.
It is also important to increase positive emotions. In DBT there is a concept of “accumulating positives” by building up positive experiences that can help you develop resilience. These can be built in the short or long term.
Once patients understand their emotions and vulnerabilities, the next step is to know what to do with them. Opposite action to emotion is the practice of recognizing the emotion and the target behavior that you would typically use to soothe that emotion, and instead doing the opposite: choosing to drink a glass of water or go for a walk instead of drinking alcohol, for example. You may also work to problem solve if there is a solution to be found.
Interpersonal Effectiveness
Interpersonal effectiveness is all about building your interpersonal skills to negotiate and compromise effectively. Assertiveness training — without being aggressive or falling into quiet despair — can be one of the hardest skills to learn here. It’s important to stay in the moment and be aware of your feelings throughout the conversation.
Listening skills are also important: fully hearing the other person will help you better understand their needs and yours. When you do so, you can more effectively negotiate with them. As your interpersonal effectiveness skills build, you’re more easily able to meet your needs. When you do so, your self-respect begins to grow.
In DBT, patients are encouraged to stay curious and ask questions to gauge the situation, such as:
- How are you feeling?
- Are you okay?
- Are we okay?
- How are things between us?
Another common interpersonal effectiveness strategy in DBT is DEAR MAN. DEAR MAN is an acronym designed to lead patients through the steps of clearly and calmly expressing themselves and broaching a difficult discussion. This serves as an outline:
- Describe the situation
- Express how that made you feel
- Assert yourself calmly but firmly
- Reinforce your feelings
- be Mindful throughout the conversation
- Appear confident
- Negotiate with the other person and be open to their side
Does DBT Work?
More than a dozen randomized controlled trials have been done to test the efficacy of DBT. These have overwhelmingly found that DBT resulted in a reduction of:
- Self harm
- Suicide attempts
- Hospitalization
- Treatment dropout
- Feelings of hopelessness and anger
- Substance abuse
There was an especially notable reduction in self-harm and substance abuse when it came to binge eating and purge behaviors. Even more glowingly, 77% of patients no longer met the criteria for BPD after finishing DBT treatment.5 Overall DBT has been found to be very effective for patients with BPD.
Is DBT Right For You?
When considering whether or not DBT is right for you, your mental health providers will take into account your:
- Past history of trauma
- Past and present relationships
- Self-harm behaviors
- Substance use
- Binge eating
- Maladaptive behaviors
- Other coping skills you’ve used up to this point
- Distress level
You may have to run through the diagnostic criteria for borderline personality disorder before beginning DBT. However, even if you do not meet the criteria for BPD, DBT may still be helpful.
It’s also worth noting that not all DBT is comprehensive DBT. Your therapist may bring DBT skills into your individual therapy, blending it with similar therapies like CBT or Acceptance and Commitment Therapy (CBT). If you’re not sure if DBT is the right therapy for you, this can be a great way to try those skills and methods without making a big change.
Curious about DBT for yourself? Rivia Mind can help. We work with a number of skilled and compassionate clinicians experienced with DBT therapy. We also offer regular DBT group therapy courses – visit our page to learn more, sign-up or join or waiting list. Contact us today to learn more about Rivia Mind and the services we offer or to schedule a free 15-minute consultation.
Resources:
- Marsha Linehan Acknowledges Her Own Struggle With Borderline Personality Disorder – Psych Central
- DBT Skills Training Handouts and Worksheets – Marsha Linehan, 2014
- Borderline Personality Disorder (BPD) – PsychDB
- Suicide Risk in Personality Disorders: A Systemic Review – McClelland, Heather; Cleare, Seonaid; and O’Connor, Rory C., 2023
- How Does Dialectical Behavioral Therapy Help People With Borderline Personality Disorder? – DBT & Mental Health Services
